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We describe a multiple sclerosis patient presenting with compression of the internal jugular vein caused by aberrant omohyoid muscle. Previously this patient underwent balloon angioplasty of the same internal jugular vein. Ten months after this endovascular procedure, Doppler sonography revealed totally collapsed middle part of the treated vein with no outflow detected. Still, the vein widened and the flow was restored when the patient’s mouth opened. Thus, the abnormality was likely to be caused by muscular compression. Surgical exploration confirmed that an atypical omohyoid muscle was squeezing the vein. Consequently, pathological muscle was transected. Sonographic control three weeks after surgical procedure revealed a decompressed vein with fully restored venous outflow. Although such a muscular compression can be successfully managed surgically, future research has to establish its clinical relevance.

The full article is available. This is a case study from Dr. Simka. The patient had muscular compression of the jugular. Flow was physiological, sometimes closed, sometimes functional. The vein would open when the patient opened her mouth. Treatment was by transecting the muscle, but although flow was improved, it did not result in any MS improvements. What is interesting also is that no other stenoses were found, only the muscular compression of one jugular. I would suggest that this patient would benefit from another look-over of the usual veins. I know there are patients in whom only one narrowing is found, but for the only narrowing to be a physiological narrowing seems like a rarity to me. This is with all respect to Dr. Simka who is not only one of the CCSVI pioneers but also contributing to the CCSVI medical literature by publishing on what he has seen.

edit: ok upon rereading, I think the left jugular did have both the muscular compression and a bad valve.

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The omohyoid muscle is the best landmark for identifying the internal jugular vein (IJV); thus any variation in this muscle may increase the risk of injuring the IJV during surgeries in the lower neck region. Because of the direct adhesion of the intermediate tendon to the anterior wall of the internal jugular vein and their connection through a thin lamina of the pretracheal layer of the cervical fascia, the contraction of the omohyoid muscle has a direct effect on the lumen of this vessel.

The wide variability of the position of the omohyoid muscle is likely to have implications for the surgical management of oral and oropharyngeal cancer, as would the short omohyoid muscle, as in our case (Figure 3). Compression of the internal jugular vein by the short omohyoid muscle may lead to modifications in intracerebral venous hemodynamics, which can be affected during yawning.27

In Simka's study, yawning improved blood flow. Short omohyoid muscle = bad; longer omohyoid muscle = good? What about neck stretches, would they lengthen the omohyoid muscle, instead of such measures as botoxing the muscle or snipping the muscle?

The action of the omohyoid muscle on the hemodynamics of the internal jugular vein is controversial. For some authors, contraction of this muscle, by tightening the cervical fascia, promotes jugular venous return. For others, contraction of this muscle compresses the jugular vein in its cervical path. With this latter point in mind, the hemodynamics of the internal jugular vein have been studied in its cervical path by echography in 10 healthy volunteers. One hundred twenty measurements of the venous surface were made at rest, with the mouth open and during deep inspiration. In the last 2 situations, evidence of a significant increase in the venous surface was found above the omohyoid muscle. These data confirm the role of compression of the vein by the omohyoid muscle, leading to modifications in intracerebral venous hemodynamics, which can be affected in yawning.

If the vein dilates above the omohyoid muscle when the mouth is open or yawning, then the yawning is affecting the vein negatively, causing a narrowing where the omohyoid muscle is compressing it and therefore a dilatation above the compression? So, yawning is not helpful, and we should not go around with our mouths open catching flies?

I would suggest that measurement of 10 normals does not preclude a critical, opposing role such as Dr. Simka found in a non-normal patient. Also, yawning while lying down may be quite different in effect on a blocked jugular than in normals. In fact, if none of the normals had expansion while yawning, perhaps many "MS" patients would. Maybe yawning should be a requirement during the CCSVI procedure, as well as going from prone to erect, and it's probably a good thing I don't have to decide.

I yawn a lot both when lying down and erect. Maybe yawning is normally a prompt to get some sleep? I have heard recently of someone with leg lifting only when yawning. Is that correct? Is it different when prone, for that person?

I suggest this at best shows yawning is not helpful when you are normal, and that I don't even know whether the yawners were prone. Jugulars are normally not used much when erect, so I expect so. Didn't read enough of the paper, I guess.

1eye wrote: I have heard recently of someone with leg lifting only when yawning. Is that correct? Is it different when prone, for that person?

That would perhaps be me. I have made posts about that several times. With regard to the second question; is it different when prone, I think you mean in the supine position. When I am standing I can barely lift my left foot off the floor. But when lying flat on my back I can lift my foot by bending from the hip until the leg is nearly straight up. Does that answer your question? Does it mean anything? That's a question I've been pondering.

Just for info, I have ppms, dxed about 18 years ago. All of my problems are on the left side and mostly with the leg.

I think that may be because you are flexible enough. The only way I can lift my leg when sitting is to straighten it. On my back, the only way I can bend my leg is very slowly, and using both hands helps in both situations, partly because I still have some proprioception and when hands are there I can make the leg respond somewhat.

It does seem quite different from my bum leg, if you can do that. I think what I might have been thinking is "does the yawning effect change any when you are lying down?"

I am interested to do exams about the omohyoid muscle . Does anyone know who can do that type of exam and how ?

I believe that Simka's case report had a very intense problem that was very obvious. I also believe that many patients may have that kind of problem but noone knew how to exam that . I think that maybe I have that kind of problem because I had 2 angioplasties and no results . The blood flow seemed ok in the ultrasound but I wasn' t feeling good.

I had an MRA that showed an annulus again in the right vein but the doppler ultrasound showed that the flow was ok . Now I don' t know what to do and noone tells me but I think I maybe have and other problems out of the vein . Before the angioplasties I had edss 2 and now I have 4 .

A CT scan might show it. That shows everything external to the vein, doesn't it? With these sorts of external compression narrowing of the veins, you're looking for narrowing at the top of the vein near the skull base or in the middle of the vein, and you'd be looking for what causes the narrowing.

During a CCSVI procedure, if there appears to be a narrowing but the vein expands when you hold your breath and bear down in a valsalva movement, that is evidence that there may be an external compression. I had this during my procedure, and it went untreated because ballooning won't help this sort of compression. Sticking a stent in could cause the stent to be compressed against bone, which could damage the stent and worsen the flow. So the solution is do nothing, since it's unclear if narrowings that are inconstant (sometimes open, sometimes closed) do any harm, or the solution is to get it surgically taken care of, or the solution is to botox the muscle which has not yet been tried for this condition and which carries some serious risks of its own such as choking.

It's possible that no results after angioplasty is because not enough was done, or it's possible that it's the MS that is the problem and not the CCSVI. Other things that could be going on are compression of the innominate vein, which is what the jugular vein flows into, or compression of the renal vein, which redirects flow into the cerebrospinal drainage system/azygous vein/lumbar veins, or early restenosis of whatever was treated, or blockages that were missed that might've been caught if IVUS was used, or ... I am sure there are more.

Could a DO/doctor of osteopathy be the right doctor to see? I am guessing here.

According to Harrison's Principles of Internal Medicine, "the training, practice, credentialing, licensure, and reimbursement of osteopathic physicians is virtually indistinguishable from those of physicians with M.D. qualifications, with 4 years of osteopathic medical school followed by specialty and subspecialty training and [board] certification."[8] However, D.O. schools provide an additional 300 – 500 hours in the study of hands-on manual medicine and the body's musculoskeletal system, which is referred to as osteopathic manipulative medicine.[1]

http://medicine.hsc.wvu.edu/Surgery/Med ... Outlet.pdfsome tests under clinical diagnosis halfway through that document; also lists physical therapy and postural therapy as potential avenues; this is looking at TOS which can include congenitally shortened omohyoid muscle

That's very interesting Cece. When I had my neck surgery last Oct, they removed the middle part of the hyoid bone, so I am assuming the omohyoid muscle was cut in some way in my case. Must say it was a rather painful op. Still feeling well, and no blood-letting needed for nearly a year now. Could be my cyst was cutting off more than just my airway?

Cece I had a treatment by Dr Sclafani last September so I think the diagnosis was right . He looked and the renal vein and he said it was ok . To be the MS ? I don't know , I have all the ccsvi symptoms . Every day headache , fatigue, dizzyness nothing is good . I am very nervous , I cannot concentrate and I have many other problems . Also a have a clot in my left vein but Dr Schelling told me that the lesions are from my right vein and not from the left . I don't know. This ccsvi adventure cost me a lot and I haven't seen any benefit . I can say now I am worst than before .That' why I think everything . In order to stop suffer so much

Here are some testimonies http://www.ccsviitalia.org/cm-testimonianze.htmlI did the test for the CM and I am positive . I think that this is a good reason of why I after two venoplasties I feel worst than before and worst than ever . I am looking forward to do something about this muscle ..

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